Providence St. Joseph Health's Primary Care for All plan includes capitated payments, quality measures, and risk adjustment.
A Washington state-based health system is proposing a seven-point plan featuring Primary Care for All to address racial disparities in healthcare.
Racial disparities have plagued the healthcare sector for years. For example, black, American Indian, and Alaska Native women are two to three times more likely to experience maternal mortality than white women, according to the Centers for Disease Control and Prevention (CDC). The coronavirus disease 2019 (COVID-19) pandemic has highlighted healthcare racial disparities, with black Americans five times more likely to be hospitalized for COVID-19, the CDC has reported.
To respond to the problem, Renton, Washington–based Providence St. Joseph Health (PSJH) is proposing seven ways to rise to the challenge.
1. Primary Care for All: Offering free primary care for every American would level the healthcare playing field and help ensure people of color have an equal chance to live the healthiest lives possible.
2. COVID-19 resources: Healthcare organizations and policymakers need to ensure that coronavirus testing and drug therapies are available to all minority communities.
3. Patient outreach: Healthcare organizations need to work directly with minority communities to meet social determinants of health needs and understand how to deliver services in a way that is culturally respectful and builds trust.
4. Voter education: PSJH is committed to educating voters about ballot initiatives that affect all Americans. The health system also plans to support voter registration drives in the seven states that the organization serves.
5. Promote the Census: The U.S. Census is an essential way to identify minority populations and allocate federal resources including healthcare programs appropriately.
7. Diversity, equity, and inclusion: Earlier this year, PSJH established a social responsibility platform that features a stronger commitment to diversity, equity, and inclusion at the health system and the communities it serves.
Pushing Primary Care for All
PSJH's president and CEO, Rod Hochman, MD, recently shared his health system's perspectives on Primary Care for All with HealthLeaders.
Primary Care for All has five main elements, he says.
1. Capitated payments: "My primary care physician would be paid one fee at the beginning of the year to provide my primary care. It would be fully paid for up front. That way, the primary care office could take care of me without having to be paid every time I come into the office. They would get paid whether they talk to me on the phone or whether they talk to me on the computer," he says.
2. Quality measures: To make sure primary care physicians are taking good care of their patients, they would be held accountable by quality measures—most of which are already in place such as vaccination rates and patient satisfaction scores.
3. Increased utilization of advanced practice providers: To address an expected shortage of primary care physicians even under the current system, primary care practices would boost utilization of advanced practice providers such as nurse practitioners and physician assistants. "Under the current system, a primary care physician can take care of about 1,800 patients. Under the Primary Care for All model using primary care physician extenders such as physician assistants and nurse practitioners, that number goes up to as many as 6,000 patients," Hochman says.
4. Risk adjustment: Patients would be risk-adjusted into high-risk, medium-risk, and low-risk categories. For example, elderly Medicare patients would be categorized at higher risk than young patients because they tend to have more health issues and require more costly care.
5. Government subsidies: The government would subsidize the primary care costs of uninsured Americans. "It would not be the Medicare premium—it would just be paying for primary care. But it would ensure that every American would have a card that would give them access to primary care," he says.
How Primary Care for All would address healthcare disparities
Under Primary Care for All, every American would have a primary care coverage card, which would turn patients in every community into paying consumers of services, Hochman says.
"So, if I set up my practice in South Central Los Angeles or Roxbury in Boston or in any area that has been underserved for healthcare, all of those patients would be paying patients. It would encourage practices to set up in those communities because everyone is a paying customer, and primary care physicians would get paid up front."
Primary Care for All would encourage young physicians to go into primary care and to serve disadvantaged communities, he says.
In many countries, strengthening primary care through the Primary Care for All model has been a crucial element in improving public health, Hochman says.
"We have seen this model work in many nations that are less fortunate than the United States economically. They have put in a strong primary care net, and it significantly improves the health of the population. It provides prenatal care, preventive care for diabetes, vaccination, and all of the things that get lost in our current system because economically disadvantaged patients do not have access to good primary care."
Financial case for Primary Care for All
From a financial perspective, enacting Primary Care for All would be much more practical than more ambitious healthcare reform proposals such as Medicare for All, he says. "What we have been looking for is a solution that would do more to promote the health of Americans, but not necessarily break the bank, as people have talked about Medicare for All as a solution."
Primary Care for All would require Medicare, Medicaid, and commercial payers to carve out a modest portion of their premiums to provide primary care coverage, Hochman says. "When I think of a per member per month payment on a commercial premium, primary care is about 10 cents on the dollar."
The return on investment for carved-out primary care payments would be significant, he says. "I am getting preventive care, a safety net, and virtual care 365 days a year. I am taking care of hypertension and diabetes. And I am working on problems such as obesity and opioid addiction that have plagued the country. So, the return on investment is a pretty good one."
After decades of solid job security, many clinicians are facing challenges holding onto their positions or finding new ones, a new employment report says.
The coronavirus pandemic has dramatically reduced the demand for clinicians in the healthcare workforce, according to a new report from the clinician recruitment firm Merritt Hawkins.
Merritt Hawkins—a business division of San Diego-based AMN Healthcare—has documented strong demand for clinicians over the past three decades. However, the financial strain of the coronavirus disease 2019 (COVID-19) pandemic such as the suspension of elective surgery has led to healthcare organizations reducing their clinician workforce or cutting compensation.
"Over our 33-year history, most physicians had little difficulty finding a job opportunity, with multiple offers to choose from. Today, we are seeing a growing number who are unemployed with a limited number of roles available. This is unprecedented. COVID-19 essentially flipped the physician job market in a matter of 60 days," Travis Singleton, executive vice president at Merritt Hawkins/AMN Healthcare, said in a prepared statement.
The new Merritt Hawkins report, "2020 Review of Physician and Advanced Practitioner Recruiting Incentives and the Impact of COVID-19," examines clinician recruitment data for the one-year period ending March 31, 2020. Although the number of physician search engagements the company conducted during the period increased, search engagements conducted since March 31 have declined 30%.
"The 2020 coronavirus pandemic has changed the playing field in the physician recruiting arena, turning what was a buyer's market for physicians seeking practice opportunities into a seller's market for hospitals, medical groups and other healthcare facilities seeking to recruit physicians. As a result, for those healthcare facilities that are recruiting physicians or are planning to do so, conditions now are more favorable than they have been in years," the report says.
The new report is based on a sample of more than 3,000 permanent physician and advanced practitioner search engagements conducted by Merritt Hawkins.
The top five most requested job searches were as follows:
1. Family medicine
2. Nurse practitioner
3. Psychiatry
4. Radiology
5. Internal medicine
For physicians, the top five average income specialties excluding production bonuses and benefits were as follows:
1. Invasive cardiology: $640,000
2. Orthopedic surgery: $626,000
3. Urology: $477,000
4. Gastroenterology: $457,000
5. Pulmonology/critical care: $430,000
Assessing impact of coronavirus pandemic on clinician workforce
The new report includes several clinician workforce impacts from the COVID-19 pandemic and anticipated clinician workforce trends.
Long-term supply and demand: The clinician workforce market is expected to rebound in the long-term. Factors such as the country's aging population, U.S. population growth, and the growing number of Americans with chronic conditions are likely to fuel demand for clinicians for many years to come. Factors such as physician aging and low physician morale are likely to lower the supply of clinicians over time.
Independent primary care practices: Despite pivoting many in-person patient visits to telehealth, primary care physicians have experienced significantly lower revenues as patients avoid visiting their doctors' offices during the pandemic. "It is probable that some independently owned primary care practices will have to merge with hospitals or larger medical groups to survive post-Covid-19, further eroding the viability of the private practice model which has been in decline for years," the report says.
Rise of telehealth: The pandemic is expected to increase patient demand for telemedicine visits. Merritt Hawkins data has found that the percentage of physicians treating patients through telehealth has jumped from 18% in 2018 to 48% this year.
Primary care's bright future: Although Merritt Hawkins has found that annual starting salaries for primary care physicians have remained flat over the past three years at about $240,000, primary care services are expected to be in high demand in the future. Several factors are likely to drive demand for primary care services, including the key role of primary care physicians in care coordination and the importance of primary care physicians in value-base care models such as accountable care organizations.
Decreased demand for some specialists: Market demand for some specialists is expected to be soft during the pandemic. "Medical groups performing a high volume of so-called non-essential procedures have been unlikely to recruit additional physicians during the pandemic. For example, small- to mid-sized dermatology groups and ophthalmology groups, many of which are still independent, are not seeing the volumes they need to add staff," the report says.
Coveted specialists: During the pandemic and beyond, demand will be high for some specialists such as hospitalists, emergency medicine physicians, and infectious disease clinicians. "All of these types of specialists will be needed to both maintain population health should cases of Covid-19 persist and to prepare for the next pandemic or public health emergency," the report says.
Pandemic spurs demand for psychiatrists: Mental health professionals were already in high demand before the pandemic, which has had a significant negative impact on people's mental health. An April 2020 survey by the Kaiser Family Foundation found that 45% of American adults said the pandemic had affected their mental health. "Today, it is widely acknowledged that the shortage of mental health professionals, including psychiatrists, has developed into a public health crisis," the Merritt Hawkins report says.
Nurse practitioners and physician assistants: The number of Merritt Hawkins' search engagements for NPs and PAs increased 54% over the one-year period studied in the new report. NPs and PAs are expected to remain in high demand after the pandemic, the report says.
Employed physician model: The pandemic is expected to accelerate the shift from independent practice to the employed physician model, with independent practices lacking the resources to rise to the pandemic's financial and operational challenges. The new report found that 95% of physicians accepting new positions are practicing as employees. In 2001, about 60% of physicians accepting new positions practiced as employees.
With supplies of N95 respirator masks stretched thin during the coronavirus pandemic, decontamination of used masks can help meet demand.
Based on a review of scientific literature, there are four effective methods to decontaminate N95 respirator masks, a recent research article says.
During the coronavirus pandemic, maintaining adequate supplies of personal protective equipment (PPE) for healthcare workers has been an acute pain point. With the virus primarily spread through respiratory droplets and aerosol particles, N95 masks have been in high demand and limited supply. In March, the U.S. Department of Health and Human Services estimated that a prolonged pandemic would require 3.5 billion N95 masks but only 35 million were stocked.
Treating coronavirus disease 2019 (COVID-19) patients without adequate PPE is potentially deadly for healthcare workers. In Italy, which faced shortages of PPE and other critical pandemic resources such as ventilators in the early stage of the pandemic, about 20% of healthcare workers became infected.
To ensure adequate supplies of N95 masks, decontamination of the respirators has become a matter of necessity at many healthcare facilities. The recent research article, which was published in JAMA Otolaryngology—Head & Neck Surgery, identifies four decontamination methods that can recycle N95 masks without compromising the fit of the masks or the filtering material.
1. Ultraviolet germicidal irradiation
In a 2018 study, researchers used ultraviolet light to process 15 different N95 mask models contaminated with the H1N1 influenza virus. The ultraviolet germicidal irradiation significantly reduced virus viability in 12 of the 15 models.
In an April 2020 study, ultraviolet germicidal irradiation of N95 masks was effective over three rounds of decontamination. However, the researchers found that the UV light treatment process required more time than other decontamination methods.
In a 2009 study, exposing respirator masks to UV light for 30 minutes was found to be an effective decontamination method.
2. Vaporized hydrogen peroxide
The 2009 study also found vaporized hydrogen peroxide treatment effective in decontaminating respirator masks. In that study, researchers exposed contaminated masks to vaporized hydrogen peroxide for 55 minutes.
3. Steam treatment
In a 2012 study, microwave-generated steam and oven-generated steam were found effective in treating N95 masks contaminated with H5N1 influenza virus in droplet form.
In a Stanford Medicine study, treating N95 masks with boiling water vapor for 10 minutes was found to be an effective decontamination method for Escherichia coli bacteria.
4. Dry heat treatment
The Stanford Medicine researchers also found dry heat effective in treating N95 masks contaminated with Escherichia coli bacteria. The masks were exposed to dry oven heating at 70°C for 30 minutes.
Low-resource decontamination option
For healthcare facilities that lack the resources to adopt active decontamination methods for N95 masks such as UV light or steam heating, "time decontamination" is a viable alternative, the JAMA Otolaryngology—Head & Neck research article says.
In time decontamination, healthcare workers use an N95 mask, then store the mask in a time-stamped paper bag for reuse. "Since the surface viability of the novel coronavirus is presumed to be 72 hours, rotating N95 respirator use and allowing time decontamination of the respirators is also a reasonable option," the research article says.
If time decontamination is utilized to reuse N95 masks, the Centers for Disease Control and Prevention recommends that masks should be out of service for five days.
Change such as the adoption of new information technology can wreak havoc among primary care practice staff members.
Improving change management can reduce anxiety and burnout among staff at primary care practices, a recent research article says.
Burnout is taking a significant toll in the healthcare sector. It is estimated that a doctor commits suicide every day. Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms. A study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
The recent research article, which was published in Journal of the American Board of Family Medicine, found that change is a driver of anxiety and burnout at primary care practices.
"Primary care physicians, advanced practice clinicians, and staff experience a tremendous number of workplace changes brought about by the adoption and use of EHRs and other information technology, transformation to new care delivery models such as a patient-centered medical home or accountable care organization, transfer of practice ownership, and/or compliance to numerous regulatory and payer requirements," the article says.
The research examined data collected from more than 1,200 physicians, advanced practice clinicians, clinical support staff, and administrative staff at primary care practices. The study features several key data points.
Primary care physicians reported the highest level of burnout, at 31.6%.
A significant level of burnout was reported in all other staff categories: 17.2% of advanced practice clinicians, 18.9% of clinical support staff, and 17.5% of administrative staff.
Healthcare professionals with higher levels of anxiety and frustration were twice as likely to report burnout than counterparts with lower levels of anxiety and frustration.
Physicians with higher levels of anxiety and withdrawal were more than three times as likely to report burnout than physicians with lower levels of anxiety and withdrawal.
"Although we found that physicians experience higher burnout than other healthcare professionals, high anxiety levels were reported across health professional groups, indicating a need for programs and services that focus on all employees," the research article says.
Addressing anxiety and burnout
Methods to improve the work environment during change include increased support from leadership, targeted education and training, effective communication, and individual coaching, the research article says.
During periods of change, organizations should avoid leadership dictating mandates for primary care practices, one of the research article's co-authors told HealthLeaders.
"What we have encouraged is that policy makers and leadership in these organizations do a better job of involving the folks who are on the ground in terms of making sure they understand what is coming and are involved in the process. When change happens to you without a lot of direct involvement, the anxiety levels tend to increase significantly," said Victoria Grady, DSc, MS, an assistant professor at George Mason University School of Business in Fairfax, Virginia.
For example, if a primary care practice is owned by a health system that wants to install a new electronic medical record at the practice, health system leaders should not solely push the change, she said. "The practice and its staff should be involved in how a new EMR is chosen. They should be involved in looking at different EMR systems and how the new EMR system is going to be rolled out."
As part of the change management process, leadership should seek out clinicians and other primary care practice staff members to play an active role in initiatives, she said.
"At small- to medium-sized primary care practices, it is not difficult to identify an individual within the organization who has influence over others. It could be a physician or a staff member who has influence over folks in the organization—someone who can be on the ground explaining why change is happening, how change is going to happen, and the nuances involved."
To improve the work environment during change, leadership should be proactive and collaborative, Grady said. "It is more important than ever for leadership to be proactive in terms of defining how the influencers within the organization can be a part of the decision-making process, instead of just mandating decisions. There needs to be a collaborative, team-based approach."
Another factor in improving the work environment during change is focusing on how individual staff members will be impacted, she said.
"Leadership needs to understand the individuals who are going to be affected by change. Organizations are collections of individuals. When implementing change, you need to take the time to understand individuals within the organization and how the impact of change is going to affect day-to-day work tasks. You need to understand the behavioral change implications."
A targeted training and education program is an essential ingredient in change management at primary care practices, Grady said. "You need training and education. A lot of organizations are not integrating a detailed and proactive training program upfront before change. It is more reactionary."
Citing the new EMR adoption example, she said training and education must be provided before and during the initiative's implementation. "Leadership needs to make time to allow all of the staff impacted by change to have a meaningful education and training experience as part of the overall change strategy."
The Institute for Healthcare Improvement selects its chief innovation and education officer to succeed Derek Feeley as president and CEO.
Equity is an underpinning consideration in efforts to improve U.S. healthcare, the new president and CEO of the Institute for Healthcare Improvement says.
Kedar Mate, MD, was named chief executive of the Boston-based nonprofit last month. He is succeeding Derek Feeley, DBA, who led IHI for nearly seven years.
Mate has worked at IHI in several roles for a decade, most recently serving as IHI's chief innovation and education officer. He also has worked at Partners in Health and the World Health Organization. He earned his medical degree at Harvard Medical School and trained at Brigham and Women's Hospital.
Mate recently shared his perspectives on healthcare improvement and leading IHI with HealthLeaders. The following is a lightly edited transcript of that conversation.
HealthLeaders: How has the coronavirus pandemic exposed areas for improvement in healthcare?
Kedar Mate: COVID-19 has pried its dirty, despicable fingers into every nook and cranny of our health system that is weak. It has exposed all of the flaws and defects.
First and foremost, there are equity considerations. COVID-19 has dramatically affected populations differently in parts of the country and in racial groups. Black and brown people are—broadly speaking—more affected by COVID and they are experiencing a higher death rate.
COVID has also exposed challenges around the care continuum. Whether it be related to ambulatory care and the fragility of that system, or the acute system that is heavily dependent not only on ambulatory care but also the postacute system, which has been hard-hit by the condition. Overall, the care continuum has been significantly affected by the pandemic as we have seen the virus challenge us to generate a more integrated and cohesive system.
Lastly, we have seen how COVID has exposed the challenge of integration of healthcare and public health. It has exposed how much we have underinvested in public health for more than a decade.
HL: What is your vision for IHI?
Mate: The vision of the institute is and remains that everyone gets the best care possible. Our mission to improve health and healthcare worldwide remains.
We realize that mission and vision through a handful of major areas of focus.
One is on safe care. We will increasingly be paying attention to how to improve patient safety and the safety of our families and communities. Now more than ever, patient safety is just not about what happens in an acute care hospital but what happens across the continuum of care.
Two is around value—how do you reduce waste and drive improvement in clinical outcomes? This is an important time to be focused on this area. The pandemic has wreaked havoc on our health systems.
Third, the experience with caregivers and staff is also important. IHI has been invested in improving joy among the clinical staff for quite some time. With all that we have experienced with COVID, joy in work is more important than ever. Building resilience in our staff throughout an organization feels extremely important today.
We have to do all of this with an intentional attention to equity. We need to focus on safety, value, and experience with an underpinning of attention to inequities that are present, and the goal is achieving more equitable outcomes. … There is no quality without equity.
HL: What are two or three of the top healthcare improvement initiatives at IHI?
The first one, which I have been involved with and admire, is our work on Age-Friendly Health Systems. Over the past few years, we have created—with support from the John A. Hartford Foundation—a definition of what it means to become an Age-Friendly Health System, and we have been spreading that definition systematically throughout this country and beyond our borders. There are now more than 750 health systems that are participating, and the number keeps growing each day.
One immediate consequence of COVID has been the need for focusing the Age-Friendly Health System's attention not only on acute care but also nursing homes to try to stem the challenge of how COVID is affecting nursing homes.
Through the Age-Friendly program, we have quickly stood up a nursing home rapid response network. Every day, the network features a 20-minute huddle for as many nursing homes in the country that we can reach. It has generated knowledge about better practices to take care of older adults who live in nursing homes and for the staff who work in nursing homes every day.
A second major initiative we are working on is in the area of maternity care—a project called Better Maternal Outcomes. This project links to our pursuit of equity. We are trying to improve the experience and outcomes of black mothers, who have historically had a differential rate of adverse birth outcomes. Our work has taken that history as a starting point focused on the challenge of improving the experience of black and brown women to ensure their health outcomes are as good as they can be.
Lastly, we started work recently on pancreatic cancer, with the 1440 Foundation. This is exciting work for us, where we are turning our attention to quality- and safety-focused activities to try to improve outcomes for patients with pancreatic cancer. We are starting with pancreatic cancer, which has a high degree of clinical variation and need for better multidisciplinary care to improve outcomes.
HL: What are the primary opportunities for healthcare improvement associated with telehealth?
Mate: Every new technology introduces both risks and the promise of improving outcomes. We have to try to balance that scale more toward the promise of the technology. With the rapid expansion of telehealth, what you have seen is an enormous opportunity because it creates greater access and greater opportunities to apply the best clinical science and knowledge.
There are a number of opportunities for improvement. First is about process. How do we triage appropriately for each modality? What is appropriate for the phone? What is appropriate for video? What do we handle in-person?
There is a risk that moving to more virtual modes of clinical delivery could introduce more risk of diagnostic or therapeutic error. We need opportunities to further calibrate the application of these technical platforms to ensure that we are getting the best possible outcomes for patients and families.
Lastly, while telehealth has the potential to both expand access and address workforce shortages, there are some new challenges about how the information gets shared efficiently, how you communicate from one provider to the next, and how information might not flow seamlessly between your telehealth provider and your primary care doctor or specialist.
HL: Give examples of prime opportunities to improve patient safety.
Mate: IHI recently published a paper about how technologies that have been put in place in the electronic health record have started to generate improvements in computerized physician order entry. There have been improvements over the past decade but there are still important gaps in how those technologies are working.
There is an enormous opportunity for us to further improve infection prevention and control. If nothing else, the COVID pandemic has shown the need for greater attention to our infection prevention and control protocols, and the ways to work on them to ensure that we are ready for pandemic-like moments in the future.
Lastly, our entire safety enterprise needs to tackle safety challenges and adverse events through the application of an equity lens. The more I see morbidity and mortality reports with the equity lens being applied, the more revealing they are becoming of the challenges and defects that we have in our systems that allow for opportunities for improvement.
There is an incredible opportunity to improve the overall safety experience by applying an equity lens to our safety practice and our methods, so we are not only identifying the defects but also understanding the biases.
The novel coronavirus exposes healthcare facilities to several infection risks, including spread of the virus from asymptomatic people.
After months of grappling with the novel coronavirus, infection preventionists have developed several best practices for tackling the germ, the president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC) says.
The coronavirus—which emerged from Wuhan, China, last December—initially posed many infection prevention challenges. How was the virus transmitted to humans? How virulent was the germ? How could healthcare workers be protected from getting coronavirus disease 2019 (COVID-19)?
"Infection preventionists are certainly front-and-center during this pandemic—it is an essential role in facilities trying to deal with all healthcare-associated infections. COVID-19 presents unique risks," says Ann Marie Pettis, RN, APIC president-elect and director of infection prevention at Rochester, New York-based UR Medicine.
The coronavirus presents five primary infection prevention challenges in the healthcare setting, she says.
People can be asymptomatically infected and infectious. "With the first SARS virus, that was not the case—those patients only became infectious once they became symptomatic. What we are seeing is that we are sometimes having patients admitted who test negative but start to exhibit symptoms a couple of days later. When they are re-tested, they test positive," Pettis says.
This germ is also more infectious and easier spread than influenza virus. "The experts are still trying to figure out all of the ways the new coronavirus might be transmitted," she says.
Asymptomatic or pre-symptomatic healthcare workers going to work present a risk.
Healthcare workers have to be on guard for surface contamination. "With the surge that many facilities have experienced such as in New York, you worry about all of the surfaces getting decontaminated appropriately and whether we are letting the disinfectants sit long enough for them to kill the organism," Pettis says.
Aerosol-generating procedures such as intubating and extubating pose a high risk to healthcare workers. "All of these things can make patients cough and create more of an infectious environment," she says.
Novel coronavirus infection prevention in healthcare settings
There are seven primary infection prevention best practices for coronavirus in healthcare settings, Pettis says.
1.Telehealth: Using telemedicine capabilities for routine medical care and assessing infectious disease symptoms is going to be "a new normal," she says.
2. Triage: Assessing patients who have respiratory symptoms in tents and other sites outside healthcare facilities protects hospitals from the spread of coronavirus. "After triaging, you can send patients home who do not require hospitalization. We are even talking about creating more permanent structures rather than tents to do rapid triage," Pettis says.
3. Personal protective equipment: At UR Medicine, there is not only universal masking to prevent the spread of coronavirus at healthcare facilities but also universal eye protection for healthcare workers, she says. "For several months, our facilities have been requiring eye protection as well as masking, which has dramatically reduced the amount of exposures for our staff."
4. Patient coronavirus testing: UR Medicine is pre-testing patients who are having elective surgeries as well as procedures that require sedation.
5. Visitation policies: Limiting patient visitors helps keep the coronavirus from entering healthcare facilities. "Even though UR Medicine is loosening some limits, we are limiting the amount of time patients can have a visitor, masking visitors, screening visitors, keeping visitors in the patient's room and not letting them go to the cafeteria, and directing visitors through one entrance," Pettis says.
6. Traffic control: Patients should not spend time in waiting rooms. For example, patients can wait in their cars for appointments.
7. Staff and patient engagement: Healthcare facilities must engage staff and patients to follow infection prevention best practices. For example, staff need to be reminded continually not to come to work if they have COVID-19 symptoms, she says.
Avoiding infection in lower joint replacement surgery results in an average cost savings of about $100,000 per patient.
The use of an alcohol-based nasal antiseptic before surgery lowers surgical site infection (SSI) in lower joint replacement procedures, recent research shows.
In the United States, there are more than 1 million total joint replacement procedures annually, and that figure is expected to increase to 4 million by 2030. The average postoperative cost of a joint replacement infection is estimated at more than $100,000.
The recent research, which was published in the American Journal of Infection Control, focuses on Staphylococcus aureus infections—methicillin sensitive Staphylococcus aureus (MSSA) and methicillin resistant Staphylococcus aureus (MRSA).
"It has been estimated that S. aureus is the responsible pathogen in 63% of SSI occurring after total joint replacement. This is in part due to the fact that up to one third of the population is colonized with S. aureus on skin and nares. Consequently, some hospitals are focusing on nasal decolonization of both the patient and the surgical team in order to optimally reduce the risk of postoperative prosthetic joint infection," the study says.
The research examined the impact of pairing an alcohol-based nasal antiseptic with preoperative chlorhexidine bathing. The protocol was applied to all knee and hip replacement patients rather than targeted nasal decolonization, which avoids the cost of screening patients for MSSA and MRSA.
The study protocol featured three elements:
Patients were instructed to bathe with chlorhexidine the night before surgery
Patients received three nasal antiseptic swabs in the preoperative setting before surgery
One swab was applied twice each day after surgery while patients were hospitalized
Data was compared between a baseline period from November 2015 to October 2018 and the study period from November 2018 to October 2019. The research was conducted at Wellstar Cobb Hospital in Austell, Georgia. During the baseline and study periods, the 382-bed facility performed an average of 10 to 12 hip procedures and 25 to 30 knee procedures per month.
The results were significant:
The new decolonization protocol reduced the SSI rate for total hip surgeries from 0.91 to 0.00 per 100 procedures
The new decolonization protocol reduced the SSI rate for total knee surgeries from 0.36 to 0.00 per 100 procedures
The SSI rate reductions were estimated to avoid four joint infections annually, with a cost savings of more than $400,000
The author of the research article told HealthLeaders that the SSI rate reductions have been maintained since the study concluded in October 2019. For lower joint replacement procedures, WellStar Cobb Hospital has had only one "superficial infection" since the study ended, said Susan Franklin, RN, an infection prevention practitioner at Marietta, Georgia-based WellStar Health System.
"Additionally, after learning about the great results with total joint replacement patients, the hospital has expanded the use of the program to spine patients and 75% of spine surgeons have ordered the nasal antiseptic," Franklin said.
Low-cost interventions can achieve significant improvement in surgical site infections, she said.
"The best advice that I would offer other hospitals is that rethinking what seem to be mundane protocols in place for years can result in major positive impacts—no need to spend millions of dollars on high tech equipment or software to make a big improvement in patient care, staff utilization and satisfaction, and bottom-line costs."
Breaking down barriers that are disrupting the physician-patient relationship is a top priority for Susan Bailey, MD.
With the worst pandemic in a century punctuating her recent inauguration as president of the American Medical Association, Susan Bailey, MD, is bracing for a momentous one-year term.
On June 7, Bailey became the 175th president of the country's leading physician organization. She is the third consecutive woman to hold the post, succeeding Patrice Harris, MD.
Bailey has been a practicing allergist/immunologist in Benbrook, Texas, for more than three decades. She was first elected to the AMA Board of Trustees in 2011. Before becoming an AMA officer, Bailey served as president of the Texas Medical Association and Tarrant County Medical Society.
Bailey earned her medical degree at Texas A&M University College of Medicine. She completed her residency and fellowship training at the Mayo Graduate School of Medicine.
In a recent interview with HealthLeaders, Bailey shared her perspectives on the top issues facing physicians and her plans as AMA president. The following is a lightly edited transcript of that conversation.
HealthLeaders: What is it like to become the leader of the AMA in the middle of a deadly pandemic?
Bailey: To become president of the AMA in the middle of a pandemic is a bit surreal. Usually, an AMA president is inaugurated at our annual meeting and there is lots of fanfare, but I gave my inauguration speech in front of a camera in a quiet studio. Then I just started doing the job.
The responsibility is so incredible. We will get through this pandemic, but the only way that we can do it is by working together, and it is difficult to work together when we can't have meetings and can't see each other.
It is incumbent on the AMA and me to make sure that we fully utilize all of the technology that we have at hand to be able to reach out to our colleagues, our patients, regulators, and legislators to get our message across.
HL: You have made the removal of barriers between physicians and their patients such as burnout a priority. How do you plan to achieve this goal?
Bailey: I am very passionate about protecting the physician-patient relationship. There are many entities that are interfering with that relationship, and each must be dealt with in turn.
Attacking the dysfunction in healthcare will require working in Washington as well as at the state level to minimize the burdens that are interfering with patient care. The concerns include prior authorization from payers, payment policies, and burnout. All of these concerns are going to have to be approached differently. Fortunately, we have the power of the AMA to help us do that.
There is growing awareness that burnout is a health system problem—it is not an individual problem. Burnout is not a moral failing or weakness. Burnout is the response to not being able to take care of your patients in the way you have been taught.
The AMA is looking at ways to prevent burnout, primarily by attacking the dysfunction in healthcare. We think burnout begins in medical school, and we support reasonable duty hours as well as residency and fellowship programs to address burnout and provide mental health resources.
Our strategic initiative to improve health outcomes, to remove the dysfunction in healthcare, and to design the medical education system of the future are all working to provide burnout solutions at the individual level, the practice level, and the health system level.
HL: Give an example of a payer issue that is creating barriers between physicians and their patients.
Bailey: Prior authorization is what jumps to mind immediately. I am an allergist in private practice. I have been in the same small, single-specialty practice for more than 30 years. A big part of my practice is prescribing medications. There are incredible and often ridiculous requirements to get my patients the medications that they need. It is completely out of control.
By some estimates, doctors and their staff spend up to two days a week trying to deal with prior authorizations. The AMA has worked with a group of payers in the past and set some goals; but, unfortunately, the problem just continues to get worse and worse.
It is going to be important to go back to the drawing board with the payers, investigate legislative solutions, and not rest until we get this problem fixed. It will be interesting to see whether we can get the prior authorization rollbacks that have happened during the coronavirus pandemic to persist.
HL: For physicians, what tops the agenda in addressing the coronavirus pandemic?
Bailey: The coronavirus pandemic has predominated all of our thoughts and work over the past few months. The bottom line is that we must be able to safely and effectively treat coronavirus patients. To do that, we must have plenty of personal protective equipment and other supplies to protect our patients as well as protect healthcare workers and their families.
Another area is the non-coronavirus care that is currently being delayed because of the pandemic. We need to encourage patients to continue to receive their chronic care—for their diabetes, their hypertension, and other conditions. Children need to be getting their immunizations—surviving a coronavirus pandemic will not do us much good if we end up with a measles epidemic because children have not been able to get their immunizations.
HL: Do you think the pandemic is going to spur permanent changes for physicians?
Bailey: Remote care and telehealth have been front and center during the pandemic. At my practice, telehealth has enabled us to continue to take care of our patients.
We are very grateful that the Trump administration has reduced many of the barriers that have inhibited physicians from using telemedicine in the past—the payment policies and the privacy requirements. A lot of these new policies have implications for patients that are not limited to the pandemic. The AMA believes these new policies should be permitted to continue after the coronavirus public health emergency ends.
The AMA recently delivered a letter to Centers for Medicare & Medicaid Services Administrator Seema Verma that provided examples of telehealth policies that should continue under Medicare after the coronavirus public health emergency. We must be able to continue to serve patients in their homes. We must facilitate the use of telehealth services in different ways outside of the home and make sure physicians can supervise patient services using telecommunications technology.
Fortunately, the telehealth genie is out of the bottle, and I am looking forward to continuing to serve my patients with telehealth. Most specialties are going to devise recommendations on what should be done through telehealth and what needs to be done face-to-face. However, if we are not able to pay for telehealth services in the future, those recommendations are not going to be very helpful.
Safety, managing surgery backlogs, and telemedicine are key elements of reopening ambulatory surgery centers during the coronavirus pandemic, an ASC chief medical officer says.
With the nationwide cancelation of most elective surgeries in March to boost hospital capacity to care for coronavirus disease 2019 (COVID-19) patients, ASCs experienced a dramatic reduction in patient volume. Now, ASCs are reopening with measures to do so safely and efficiently.
"We dropped from 100% volume to about 10% to 15% of volume for an extended period," says Dan Murrey, MD, chief medical officer of Deerfield, Illinois-based Surgical Care Affiliates.
SCA is a division of Optum, which is owned by UnitedHealth Group. SCA has 230 ambulatory surgery centers in 35 states. The facilities are joint ventures with physicians and health systems.
"We are now at about 90% of our pre-COVID volumes. We are feeling very encouraged about the rebound in demand and our ability to safely manage that rebound," he says.
1. Ensuring patient and staff safety
"A lot of focus has had to be put on the safety requirements and the screening practices for patients, staff, and anyone entering the building," Murrey says of reopening SCA facilities.
SCA has enacted eight primary safety measures at its facilities:
Universal masking
Social distancing
Allowing only one visitor per patient
Uniform coronavirus testing of patients at all SCA facilities in partnership with Secaucus, New Jersey-based Quest Diagnostics
Everyone who enters an SCA facility is asked a series of questions such as whether they have been exposed to anyone known to have COVID-19 and whether they have COVID-19 symptoms. They also undergo temperature testing for fever. Anyone who fails in the screening is turned away and asked to self-quarantine or test for COVID-19.
Limiting the number of staff who enter an SCA facility to essential personnel
SCA, joint venture partners, and SCA's corporate parents have drawn on financial reserves to keep surgical teams on the payroll during the pandemic. "We did not have to rehire people, we did not have to go out and recruit, and the teams know how to work together. Having that consistency improves quality, it improves surgical outcomes, and it improves patient safety," Murrey says.
Testing patients preoperatively for COVID-19 is a critical factor, he says. "In this case, ASCs have a safety advantage over hospitals, which have to take care of patients who have COVID. By not having to treat COVID patients, our facilities are confident that we can create a safe and secure environment, with the screening, the testing, and the personal protective equipment."
2. Managing surgery backlogs
A significant reopening challenge for ASCs has been coping with procedure backlogs.
Efficiency has been prime consideration in addressing surgery backlogs at SCA facilities, Murrey says. "We offered assistance to schedule procedures that had been previously rescheduled by our surgeon partners, and we changed the protocols for how we managed workflow within the facilities to try to optimize efficiency in face of the changes that had to be made due to the safety standards."
Physicians also received clinical guidance to help them address procedure backlogs, he says. "We have created a medical executive board, which is a national policy making body with physicians from across the country. That body met regularly to create guidance on what the most appropriate clinical standards should be and what types of cases should be done first."
Safety was paramount in prioritizing which backlogged procedures were performed first, Murrey says. "From a clinical standpoint, we started with cases that were less likely to spread disease. So, we started with procedures that were non-aerosol-generating surgeries that could be done under regional anesthesia without manipulating the airway or intubating."
"We have more than 8,000 physician partners who operate in our facilities. Most physician practices were not doing extensive telemedicine prior to the pandemic; but, clearly, telemedicine was going to be the quickest way to not only see their patients in follow-up but also to begin seeing new patients again."
SCA provided physician partners with a telemedicine playbook, Murrey says.
The telemedicine playbook includes four crucial elements, he says.
Selecting the right technology
Training staff to manage the technology
Educating patients on how to access telemedicine visits and how to participate in video conferencing
Documenting telemedicine visits appropriately such as making sure that documentation meets all compliance standards and coding to charge for visits
Demographic factors such as population growth and aging are the primary drivers of the expected physician shortfall.
Physician demand will grow significantly higher than supply through 2033, according to a new report commissioned by the Association of American Medical Colleges (AAMC).
The projected shortage of physicians is worsening. Last year, the AAMC projected the shortfall of physicians at as many as 122,000 by 2032. The new report released today projects the shortfall at as many as 139,000 physicians by 2033.
The new report includes several key findings:
By 2033, the projected shortfall of physicians ranges from 54,100 to 139,000.
By 2033, the projected shortfall of primary care physicians ranges from 21,400 to 55,200.
By 2033, the projected shortfall of non-primary care physicians ranges from 33,700 to 86,700. The physician shortage in surgical specialties ranges from 17,100 to 28,700. The physician shortage in medical specialties ranges from 9,300 to 17,800. The physician shortage in other specialties ranges from 17,100 to 41,900.
Driving the data
Two demographic factors—population growth and aging—are the primary drivers of the projected increasing demand for physicians through 2033, according to the new report.
Through 2033, the U.S. population is expected to grow by 10.4%, rising from about 327 million people in 2018 to 361 million people.
The population under age 18 is projected to grow 3.9%, which would lead to low growth in demand for pediatric specialties.
The population of people 65 and older is projected to grow by 45.1%, which would lead to high demand for physician specialties that care for geriatric patients.
Retirements are expected to thin the ranks of physicians through 2033. "More than two of five currently active physicians will be 65 or older within the next decade. Shifts in retirement patterns over that time could have large implications for physician supply. Growing concerns about physician burnout, documented in the literature, suggest physicians will be more likely to accelerate than delay retirement," the new report says.
Coronavirus pandemic impact
The coronavirus disease 2019 pandemic is expected to have several short- and long-term impacts on the physician workforce, the new report says.
The pandemic is likely to affect the physician educational pipeline such as cancelation of clinical rotations and other interruptions in physician education.
The pandemic is likely to affect physician regulations such as changes in licensure.
The pandemic will have an uncertain effect on physician workforce exits, with early burnout-induced retirements potentially lowering the physician supply and the weakened economy potentially increasing the physician supply as doctors delay retirement.
The pandemic will likely affect the specialties that new physicians select such as an increased number of doctors choosing to work in infectious disease.
